In China, health care is scalpers, lines, debt

BEIJING — Mr. Li, a 64-year-old retiree with an upset stomach, reached Beijing's most famous hospital one morning recently, ready to see a doctor. He brought a blanket, newspapers and a bag of fruit.

With any luck, he would stand in line for just 26 hours.

Lining up all day and all night for a doctor's appointment, or buying one from a scalper for 30 times the official fee, are hardly unusual in China, where more than one-fifth of the world's population relies on a health-care system that is failing.

Global health experts, doctors and, most recently, government officials are unanimous: China's medical system faces a growing crisis. Government investment in health care has declined radically for two decades, sending hospitals and doctors on a chaotic foray into the free market and leaving hundreds of millions of Chinese without affordable or competent service.

Underlining the scale of the problem, a top government think tank announced last month that China's 20-year medical reform started in the early 1980s is a "failure." A new study in the New England Journal of Medicine says China's health-care problems "make those of the United States seem almost trivial by comparison and . . . constitute a major potential threat to China's domestic tranquility."

The threat is not just to China. The health-care woes of the world's most populous country have growing relevance outside its borders, experts say, as nations re-examine the challenge of containing epidemics such as severe acute respiratory syndrome, known as SARS, or deadly new strains of the flu.

"In the area of infectious diseases and biological threats, we have to realize that the [global] system is only as strong as the weakest link," said Henk Bekedam, head of the World Health Organization in China. "These diseases know no borders, so if there are countries that are weak, we, globally, need to be helping each other."

Faced with soaring prices in many areas, 49 percent of Chinese recently polled nationwide said they cannot afford to see a doctor when they become ill, according to the Health Ministry.

China's feeble health system can seem an odd contrast to the country's galloping modernization, but the two are related. For 30 years after the Communist Revolution in 1949, China relied on a socialized health-care system managed by collective farms and factory communities and staffed by legions of lightly trained "barefoot doctors." It was threadbare but functional, and life expectancy nationwide doubled within a generation, from 35 to 68 years.

In the late 1970s, political leaders embarked on the market reforms that have unleashed the economy, raised living standards and opened new realms of personal freedom. Yet those reforms also have unbraided the social safety net, dismantling collectives and sharply reducing central government spending on health care. Millions of people lost their insurance virtually overnight, while hospitals now are competing on the open market.

"The Chinese are suspended between a state-run health-care system and a market-oriented system," said David Blumenthal, co-author of the New England Journal article and director of the Institute for Health Policy at Massachusetts General Hospital. "The result has been huge problems with cost and with quality--the worst of both worlds."

Rural areas at risk

Rural areas are particularly at risk because they lack the money to support modern hospitals. In one stark measure, infant mortality rates are growing in some parts of rural China, even as national economic growth hurtles forward. And certain infectious diseases that nearly were under control, such as schistosomiasis or "snail fever," have returned in parts of the countryside, health experts say.

Sapped of government funding, state-owned hospitals are increasingly profit-oriented. Patients who go in for toothaches are urged to get expensive procedures, such as MRIs or CT scans. Half of all pregnant women at some hospitals undergo Caesarean sections, at prices roughly twice that of a normal delivery. Antibiotics and name-brand medications are routinely overprescribed. And patients are increasingly expected to tip their doctors with a hong bao, or red pouch, named for the traditional envelopes that carry cash on holidays.

"Basically, farmers can't afford to see doctors. If there is one family member who is sick, then the whole family will be poor," said Liu Guiyun, a 35-year-old peasant with a chronic cough who rode the train from Inner Mongolia to seek help at the capital's most storied hospital, Peking Union Medical College Hospital.

Her husband, Zhan Yanpo, waited in line overnight and won an appointment with a specialist, who ordered a CT scan at a cost of about $90--roughly a month's income for an average family in rural Inner Mongolia. Zhan says they already have spent 80 percent of their income this year on medical bills.